The following optional form may be used by an agent to certify facts concerning a power of attorney.

1. (1) the Principal is alive and has not revoked the Power of Attorney or my authority to act under the Power of Attorney and the Power of Attorney and my authority to act under the Power of Attorney have not terminated;
2. (2) if the Power of Attorney was drafted to become effective upon the happening of an event or contingency, the event or contingency has occurred;

3. (3) if I was named as a successor agent, the prior agent is no longer able or willing to serve; and

   (4)________________________________________________________________

   ________________________________________________________________

   ________________________________________________________________

   ________________________________________________________________

   (Insert other relevant statements)

   SIGNATURE AND ACKNOWLEDGMENT

   __________________________________ _______________

   (Agent's Signature) (Date)

   ____________________________________________

   (Agent's Name Printed)

   ____________________________________________

   ____________________________________________

   (Agent's Address)

   ____________________________________________

   (Agent's Telephone Number)

   This document was acknowledged before me on _________________,
   (Date)

   by ______________________________________.
   (Name of Agent)

   ________________________________________ (Seal, if any)

   (Signature of Commissioner of Superior Court/Notary)
   My commission expires: _________________________

AGENT'S CERTIFICATION AS TO THE
VALIDITY OF POWER OF ATTORNEY
AND AGENT'S AUTHORITY

State of ______________________________

County of ____________________________

I, _____________________ (Name of Agent), certify under penalty of false statement that ____________________ (Name of Principal) granted me authority as an agent or successor agent in a power of attorney dated ________________________.

I further certify that to my knowledge:

(P.A. 15-240, S. 42; P.A. 16-40, S. 9.)

History: P.A. 15-240 effective July 1, 2016; P.A. 16-40 changed effective date of P.A. 15-240, S. 42, from July 1, 2016, to October 1, 2016, effective May 27, 2016.